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APPLICATION WR41%,riaSAN JOAQUIN COUNTY PUBLIC HEAL ENVIRONMENTAL HEALTH DI446 N SAN JOAQUIN, PHONE (204ZD'P O BOX 2009, STOCKTON, CPERMIT EXPIRES 1 YEAR FROM DED (Complete in Triplicatte - Application is hereby made to San Joaquin County,for a permit to ,construct and/or install the work herein described. This application is made in Compliance with San Joaquin CountyOrdinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Nam�-"rl� 1 �'�� Address ,n —_ Phone ContraOLi'cense ��Phone TYPE OF WELL/PUMP: NEW WELL ❑ A WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION , SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i< -i;,DISTANCE.TO_NEAREST_-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL "- OTHER WELL-:- PITS/SUMPS. - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industr 1 ❑ Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout �\ I I Irrigation -___Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone U Type of Pump , H.P, State Work Done i Well Destruction O Well Diameter Sealing Material Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR)ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is . r available within 100 feet.) Installation will serve: Residence Commercial _ Otiier Number of living units: Number of bedrooms C91[f Character of soil to s depth of 3 feet: An r% - - tf � Water table depth a i SEPTIC TANK O Type/Mfg c No. Compartments PKG. TREATMENT PLT, Cl �'UBLIC p�T COUNTY Method of Disposal Distance to nearest: Well V my H��ftperty Line IVISirltv LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Sire Number .SUMPS. �_ Ll Distace to nearest: Well Foundation Pro 1 .- � na - .. - Property Line DISPOSAL PONDS ❑ ....- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County f Home owner or licensed agent's signature certifies the following: "I certify that in the performance'of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation.lawa of-California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu Lt1equired inspec •ons...Complete drawing on arse side. j Signed X Tit •14 i date: Y. —� FOR DEPARTMENT USE ONLY Application Accepted by Axe Date / Area Pit or Grout Inspection by Date Final Inspection by ; Date J 3 4,9 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services rte, �w 445 N San Joaquin,_P O Box 2009, Stkn, CA 95201 J, INF FEE AMOUNT DUES AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. • EH 124[HEV.i/n31 Q�fG� - EH 14.2E 1_ lJ� [J ` ! J '